Friday, March 22, 2013

Clinical Psychology in the UK – where will we be in 2023?

A talk given to the South East Thames Division of Clinical
Psychology AGM Friday 22nd March 2013

Thank you.

Just to introduce myself and to set out my credentials, I
have twice now been Chair of the DCP, I’m currently the leader of a large
multidisciplinary research group at Liverpool, combining public health, primary
care and psychology, and I have myself been a user of mental health services.

So… my title today is “what will clinical psychology look
like in 2023…?”

I am hugely optimistic. The future for my profession is
bright and positive.

I know that, when I say that these days, audiences tend to
be more sceptical. The Health and Social Care Bill, the restructuring and even
privatization of the NHS … the recession, cuts in Local Authority funding…
These financial constraints and re-organisations put pressures on the
employment prospects of clinical and other applied psychologists. And with a
Conservative Government, we see a lurch to the right – in our case leading to
the danger of old-fashioned and disadvantageous forms of care provision.
Clinical psychologists, it’s argued, are facing cuts and downgrading … and our
positive vision for care is equally under threat.

But… I’m really sorry… I’m just much more positive than
that. I think we have a fantastic, even transformational, message. And I think
that, in 2023, we’ll see a robust, effective, authoritative profession.

First, a little history and context.

In 1989, as I was training to be a clinical psychologist,
the MAS - Management Advisory Service – wrote a report on the future of what
they called ‘healthcare psychology’; what we’d now call applied psychology.
Clinical, health, forensic psychology.

This was, in truth, an inside job… it was psychologists
making recommendations about their own profession. But it’s still worth quoting
their recommendations:

“In order to realise the desirable staffing patterns, it
will be necessary to aim ultimately for ...a minimum of 4,000 healthcare
psychologists ... To achieve this target it would be necessary to establish at
least 300 training posts...”

Now … there are at least 9,600 members of the Division of
Clinical Psychology alone, and we’re training 650 new graduates from the
D.Clin.Psych doctorates per year… 650 versus the 300 recommended. We have
achieved double what we aspired to achieve.

Just think about that. Our own psychologists, arguing for
investment in clinical psychology, challenged the Department of Health to
invest in our profession… and they responded by giving us twice what we asked
for.

I do understand that there are difficulties at present. I
think, to be candid, that many working people are finding the present period
difficult. But clinical psychology is hardly in crisis. We have seen major
policy and legislative support for our work. I am fully aware that there are
tensions over the development of NICE guidelines and IAPT services.But let’s take a step backwards and get some
perspective.

NICE and IAPT

I do think that the general principle of the NICE guidelines
is great – we systematically review the evidence and an expert practitioner
committee makes recommendations about best cost-effective care.

I understand the criticisms of this system – it’s
cost-effective care, not necessarily gold-standard care; the system is heavily
weighted on RCTs – randomised controlled trials – and diagnostic categories. I
am also aware that many of my colleagues feel that CBT has its limitations. But
a proportionate look at NICE guidelines should, I think, make you very
confident. Again and again, the evidence points to the effectiveness of
straightforward psychosocial interventions.

Similarly, when we look at IAPT, while I absolutely see the
difficulties, I do think that the picture is hugely positive.

I understand that CBT is not the only fruit. I’m less
sympathetic with the idea that CBT therapists are taking clinical
psychologists’ jobs; IT consultants have replaced typewriter engineers, and
that’s just the way it is. But I do agree that we shouldn’t tolerate sticking
plaster solutions and poor-quality care. Some of the aspects of IAPT concern
me.

But, again, the general principle of the IAPT programme is
wonderful – since psychosocial approaches are effective, let’s invest in them.
And… although we’ve not seen a fantastic process of implementation… the basic
idea was to see thousands of new CBT therapists (mainly recruited from existing
mental health care staff) and thousands of extra clinical psychologists
supervising them.

Vision

We also have a positive vision for care…Back in 1948, the World Health Organisation
defined health as “... a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity”, and mental
health as: “... a state of well-being in which the individual realizes his or
her own abilities, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution to his or her
community.”

These – hugely attractive – definitions were, in my opinion,
improved upon by the EU who defined mental health as “... a resource which
enables them to realise their intellectual and emotional potential and to find
and fulfil their roles in social, school and working life.”... and also – just
to make things nearly perfect – added that: ““The mental condition of people is
determined by a multiplicity of factors including biological (e.g., genetics,
gender), individual (e.g., personal experiences), family and social (e.g.,
social support) and economic and environmental (e.g., social status and living
conditions).”

That is, of course, great for clinical psychologists. We’re
helping people fulfil their potential as human beings, not treating illnesses.
This means linking to the wider Government well-being agenda – which has
significant but very positive consequences for our profession, and our
relationship with other professions.

Of course, of course, there should be one-to-one
psychotherapy. But we should also be offering more fully holistic services. We
should be linking with Jobcentre Plus employment advisers who are delivering
what are effectively wellbeing interventions for people. We should be working
with the education services.And we
should be working with the physical health services. We should be working with
employers, there’s plenty of evidence that interventions aimed at improving
people’s wellbeing - not curing their mental illnesses but improving people’s
wellbeing - is productive for employers. We should be working with 3rd Sector
organisations and the wider civil society.

And for me, this means that our employers need to be
supportive of that way of working.We
need to be remunerated and employed and contracted and commissioned to deliver
the sort of services that people say they want.

Commissioning

I think that GPs share these aspirations. GPs, for many
years, have seen their role as incorporating the protection of public health.
GPs see the whole person, across the lifespan. That means GPs have a natural
affinity for the type of care we also want.

This is important as the CCGs – the clinical commissioning
groups – get to work. Important because it is GPs, who share this vision, who
will dominate CCGs. And important, also that the Local Authority Health and
Well-being Boards will have such a significant role.

The social and political context

Our health and well-being are intimately related to social,
economic and even political issues.

My colleagues Ben Barr and David Taylor-Robinson in
Liverpool have demonstrated how 1000 deaths here in the UK can be specifically
attributed to the economic crisis. Ben and David have also revealed that the
cuts in local authority spending are falling hardest on the poorest – with
central government funds withdrawn most severely from the most deprived
communities.

This matters, because our research starts in the social and
human realities of our clients’ lives. We therefore understand that our core
business is much less about treating illnesses and much more about promoting
well-being. That’s why psychological contribution to the Office for National
Statistics programme to measure national well being, and approaches such as the
now ubiquitous 5 ways to well-being, developed in part by my colleague Sam
Thompson, are so important.

And it’s why the Health and Well-Being Boards could be so
significant and positive for our profession.

Added value

So… the future is, I think, very positive. But... what we
need to do is demonstrate the value of our work.

There’s a hackneyed phrase of Kennedy – JFK “ask not what
your country can do for you, ask what you can do for your country”. I’m less
interested in the navel-gazing of clinical psychologists and much more
interested, to be honest, in what we have to offer.

On September 1st 1967, the Nobel Prize-winning civil rights
leader Martin Luther King Jr. delivered a speech entitled “the role of the
behavioral scientist in the civil rights movement” to the American
Psychological Association.

With eloquence and passion, Martin Luther King championed
the civil rights struggle … and spoke about how people like me could and should
support the civil rights movement.This
speech is particularly relevant today.

Most powerfully, Martin Luther King said: “There are some
things in our society, some things in our world, to which we … must always be
maladjusted if we are to be people of good will. …”

If there were a Martin Luther King for 2013, he or she would
call on us to speak out, to identify and to condemn those things that should be
condemned. We should refuse to tolerate the unacceptable and to act
accordingly.

In 1967, Martin Luther King identified a number of key
issues that should be the focus for behavioural scientists; urban riots, the
Vietnam war, unemployment and civil disobedience.

It’s remarkable how well these issues have persisted over
two generations. We have seen urban riots on the streets of major UK cities in
the very recent past, we have military adventures in Iraq, Afghanistan and
Mali, we have mass unemployment and we have civil disobedience – today in the
shape of the ‘Occupy’ movement.

We would add social and economic inequalities, the credit
crisis, with its lethal impact on citizens’ well-being, and climate change. I
would add humane care for people with disabilities and mental health problems.
And the social circumstances that determine – more than any biological factors
and more than any therapy – the well-being and mental health of our clients.

Diagnosis

In 2006 I published a very simple paper with Erika Setzu,
Fiona Lobban and Peter Salmon. It was simple because all we did, in essence,
was interview people about how they had ended up in mental health care. One
quote is worth repeating at length:

Client: “I started to hear voices, but they were not nice
voices, they were horrible.”

Interviewer: “Did you recognise them?”

Client: “It was the man that abused me … I met this man that
was a builder, in construction, you know? And he said that he wanted to give me
a job, but they were all lies, he was trying to con me. He took me back to his
house, he locked the door and he had sex with me. … And then other voices as
well. I went to … hospital and the nurses were very good to me.”

Interviewer: “When you went to hospital what did they say it
was wrong with you?”

Client: “Schizophrenia, paranoid schizophrenia.”

Interviewer:“What do
you think personally?”

Client: “What do you mean?”

Interviewer: “Do you think it is what you’ve got?”

Client: “Oh yes, that’s what I have got.”

We should be ‘creatively maladjusted’ to this creeping
medicalization of human distress. Right now, the American Psychiatric
Association is preparing to publish the latest version of its diagnostic
manuals – DSM-5. It seems clear that this manifestation of the medicalization
of human distress will be more paradoxically illogical, more invalid, more
stigmatising, and more pervasively likely to pathologise normal human reactions
than ever before.

So, please, join me, Anne and Richard and others in the
audience, in registering our concern. You can do this by going to our website –
dsm5response.com – and adding your voice.

Treatment

And when it comes to treatments, there are again things to
which we should be maladjusted.

We must refuse to tolerate the cruel, inhuman and degrading
treatment of people in psychiatric care. This includes the appalling inhumanity
described – correctly – by the United Nations as "akin to torture".

But such extremes are also supported by everyday inhumanity
– and by the inadequate, cruel and uncaring treatment experienced every day and
in many (if perhaps not all) settings. On the same day I read the UN report, a
man wrote to me describing his experiences of psychiatric 'care'. The whole
incident is traumatic; from the initial involuntary admission (in handcuffs, by
the police) to discharge. I was particularly struck, however, by the everyday
inadequacy of the inpatient stay. This won't be terribly surprising to people
working in mental health care... but the fact that this account will be
recognised speaks to its truth.

My correspondent reported; "... Rather than engaging
with the patients on the ward, the staff instead shepherded them around like
sheep with bullying commands, threats of ‘jabs’ (injections), and removal to an
acute ward elsewhere in the hospital, if they did not co-operate. The staff
also stressed medication rather than engagement as a way of controlling the
patients.

And the staff closeted themselves in the ward office,
instead of being out and about on the corridors and in the vestibule where they
should have been. The staff wrote daily reports on each patient on the
hospital’s Intranet system; these reports were depended upon by the consultant
psychiatrists for their diagnoses and medication prescriptions, but were
patently fabricated and false, because the staff had never engaged or observed
properly the patient they were writing about in their reports. The
psychiatrists themselves were rarely seen on the ward, and only consulted with
their patients once a week."

I certainly recognise this account. It doesn't represent
absolutely all psychiatric units... but it isn't bizarre or unrepresentative.
It reflects - in psychiatric rather than acute medical care - the findings of
the Francis Report into uncaring and inhumane treatment in the
Mid-Staffordshire NHS scandal. And we should absolutely refuse to accept it. I
don't want to accept this as the status quo. And we should absolutely refuse to
accept it. I don't want to accept this as the status quo.

Conclusion

In the words of the European Union, good mental health is:
“a resource which enables them to realise their intellectual and emotional
potential and to find and fulfil their roles in social, school and working
life. For societies, good mental health of citizens contributes to prosperity,
solidarity and social justice”.

Psychologists are – now – and will in the future be key to
delivering this vision. In 2023 it will be recognised that clinical
psychologists are a key profession in helping people fulfil their potential as
human beings, not treating illnesses. Outcomes will be driven by real people –
service user’s – definitions of what they need as real-world outcomes. And
psychological therapies will be designed and commissioned to that end.

For us as psychologists, we will be offering a broader, more
holistic service. Yes, of course, because we’re experts in psychological
therapies, we’ll offer one-to-one therapy. But, as we’ve always wanted to,
we’ll offer more fully holistic services – linking with employment advisors,
working with education services, physical health services, with employers, with
community services.

This means rather different professional links – as much
with the Royal College of GPs as with the Royal College of Psychiatrists. And
it means better links with the other applied psychologist groups. Since a
genuine view of well-being integrates clinical psychologists’ interest in
mental health with occupational psychologists’ interest in employment,
educational psychologists’ interest in education, health psychologists,
forensic psychologists etc.

Addressing the full range of a person’s well-being means
coordinating services across a wide range of domains, across many different
services – education, health, employment. A multi-disciplinary service.

And it strikes me as pretty obvious that, within those
multi-disciplinary services, we’ll see the judicious use of colleagues trained,
rapidly, in mono-modal therapies... .

But, in 2023, clinical psychologists will be coordinating
the higher-level case formulations within which those mono-modal therapies will
be delivered.

So we should be upfront and positive. Good mental health and
well-being is a consequence of how we make sense of and understand the world,
primarily our social world. And how we make sense of and understand the world
is largely determined by our experiences and upbringing.

I believe that the future lies in helping policy-makers, the
media and commissioners realise the potential benefits of our skills, and in
integrating our work with a much wider program of improvement of health and
well being across a number of Government Departments. That requires us to be
confident and imaginative as we look to the future.

I do believe that clinical psychology is an essential profession and cannot be compared to other psychological therapies. Simply put, we sre more than therapists. We have systemic skills, managerial and supervisory roles, research knowledge and applied skills on a range of therapy. I find truly unfair and disrespectful the downgrading of clinical psychology, mostly because of the intensity training we are required to do but also because on a balance of probabilities our presence in health care is more essential than psychiatry. I know I'm a dreamer but the only way for psychology not to loose it's hegemony is by having honest psychologists going into power, even government snd legislative positions.

Hello my friend! I would like to tell you that this write-up is awesome, great written and include almost all important info. I recently came to know about http://drzarin.com/coach-for-therapists, their Clinical and Educational Psychologist Skills are very effective.Clinical and Educational Psychologist

Clinical psychology is an integration of science, theory and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically based distress or dysfunction and to promote subjective well-being and personal development.

Great and really helpful article! Adding to the conversation, providing more information, or expressing a new point of view...Nice information and updates. Really i like it and everyday am visiting your site..

Very nice post here and thanks for it .I always like and such a super contents of these post.Excellent and very cool idea and great content of different kinds of the valuable information's.GRE training institutes in chennai

The more learning we pick up, the more we develop and grow more in our life. Being accomplished never intends to procure endorsements and five digit compensation from a rumored organization, be that as it may it is likewise an approach to be a decent social individual in the life.click here http://www.psychologycapstoneproject.com/about-us/ for more information.

Got to learn a lot of things from this article. It can be used for any kind of business. Pegasi Media Group the world's leading database vendor and the most preferred organization all over the globe. Our brand is well-known in the market. The organizations of all the sizes have experienced our services and are quite pleased with it. We perform the activities like data cleansing, data appending, data updating, data validation, and data verification on a regular basis before the final delivery. You have also got the tremendous flexibility to choose the geographical location and reach out to the prospects that you target.Psychologist Email List